Evidence Based Urgent Care

I went in to urgent care today after battling an influenza-like illness that I got on a trip to Alaska, most likely in the flight home.  The symptoms are charted in the above graphic.  Without providing too much graphic detail on the symptoms, my concern was in whether or not I might have pneumonia and needed a chest x-ray.  Although I knew this was most likely not an influenza virus, the symptoms were fairly severe.  As an example, on last Saturday August 15, I had diffuse muscle pain that was so severe, I could barely move.  In the two days I took time off from work August 18 and 19, the muscle pain was restricted to chest wall muscles.  The cough had also become productive over the past 5 days.  I thought it was reasonable to get it checked out, especially against a backdrop of asthma and chronic asthma therapy.

I took my graphic along with me and showed it to the nurse and the physician.  I told her that I had bronchitis that was probably caused by a respiratory virus.  The nurse was overtly uninterested and at one point said that all she needed was a single symptom to write down and that symptom would be cough.  As she continued writing, she kept glancing at the graphic and taking additional notes.  I wanted to say: "Just scan it in and you can stop writing.  It contains almost all of the information that you need to know."  But I didn't.  I maintained standard medical office decorum.  As Seinfeld once said: "You go from the large waiting room to the smaller waiting room and wait again to see the doctor."  The nurse took all of my vitals including an oxygen saturation and stated matter-of-factly: "They're all normal."  My enthusiastic reply of "Good" was met with dead air.

The doctor walked in and I gave him a brief history.  He looked at my graphic and wrote down a few words.  He listened to all of my lung fields with a stethoscope and then listened to my heart sounds - both through my shirt.  The entire history and exam took about 5 - 10 minutes.  And then:

"You have bronchitis.  There is probably a lot of inflammation in there.  I am going to prescribe prednisone and an antibiotic.  Levaquin is a good one for this.."

At that point, I told him that I was already on two QTc interval prolonging drugs and that Levaquin might not be a good idea.

"OK then I will look up another antibiotic.  Doxycyline is one that should work.  Yes - there is no interaction between doxcycline and your medication.  Any other questions?"

I asked him about the issue of a chest x-ray.  I had three in the last two years and it seemed like the decision was a coin toss.

"I don't think so.  You have sounds all over your lungs and not in one place in particular.  If it doesn't get better I would do a chest x-ray.  Right now it is not going to change what I do."

I walked out with scripts for doxycycline 100 mg BID x 10 days and prednisone 40 mg QDAY x 5 days.  Entire length of the visit with the RN and MD about 15 minutes and I was the only patient in that clinic.

Of course all during this time, I was comparing the topology of this medical visit and medical care to the common uniformed criticisms of psychiatric care.  Just this morning and totally out of the blue somebody sent me a link to their letter in the British Medical Journal about the fact that 70% of clinical trials of paroxetine were unpublished.  He sent it in response to a post that I had made here some time ago, and apparently was unaware of the fact that I figured out that paroxetine was not a drug that I cared to prescribe by the time I had prescribed it to a second patient.  It should be obvious that unpublished clinical trials have been a significant problem in medicine for some time and that is nothing new in psychiatry.  Seems like the prevalent bias against psychiatry rearing its ugly head again.

How about the longstanding claim that psychiatric diagnoses are not valid because there is no "test" for them.  What was the "test" I got for bronchitis?  Of course there was none.  A diagnosis of bronchitis pretty much depends on the symptoms that I walked in with.  The same symptoms on the graphic that seemed to be shunned by the RN and casually interesting to the MD.  None of the measurements in the office had anything to do with bronchitis.  They were all essentially measures to look at whether or not I had any more significant disease - actually a more significant syndrome.  When I was an intern, we thought we had a more scientific way to analyze the problem.  We would obtain sputum samples and Gram stain the samples and culture them.  Once the integrity of the respiratory epithelium is disrupted there are all kinds of bacteria that colonize the area.  The sputum samples were not useful - either in terms of pathogenesis or guiding antibacterial therapy.  Thirty years later, antibacterial treatment of bronchitis is still empirical.  No specific pathogen is identified.  The thinking used to be that sputum indicated a bacterial infection, now we know it is just sloughed epithelium from the cytotoxic effect of viruses.  Empirical treatment of bronchitis is really no different than empirical treatment of any symptom defined mental illness.  Ignoring a couple hundred specific respiratory viruses is reminiscent of a hostile criticism of psychiatric nomenclature: "It is all one disease."  By comparison, acute bronchitis is also one disease.

Another interesting comparison is symptom severity.  I spend a lot of time discussing and documenting this with psychiatric disorders.  In the case of bronchitis, there was no particular interest in severity.  No questions about subjective experience, patterns of the cough, or sputum production.  You either have it or you don't.  Of course, I know that pattern recognition was in place and the physician was looking for signs of more significant illness like tachycardia, tachypnea, diaphoresis, and cyanosis.  But there were not any questions about functional capacity and how I was being affected (again more info in the graphic.)  Psychiatric diagnosis and treatment requires close attention to severity, impact on functional capacity and sleep, and whether the symptoms are in remission.

What about the "evidence basis" of the treatment?  A charitable interpretation of the e-mail about paroxetine would suggest that author was critical of the evidence basis for its use.  It is well known that over half of the drug studies from ClinicalTrials.gov are unpublished and that a significant number of the published trials omit details of interest (3) like side effects.  That same study looked at trials in 7 different medical specialties, none of them psychiatry.

It turns out that in clinical trials those adults with acute bronchitis treated with antibiotics are less likely to be rated as improved at follow up.  Some studies show a shorter duration of cough by 1/2 day but the trade off is a significant increase in antibiotic side effects with 19% of emergency department visits for adverse drug effects being due to antibiotics (1, 2).  A direct quote from UpToDate:

"Patients with known asthma may develop superimposed acute bronchitis.  It is common that such patients seek treatment and are inappropriately prescribed an antibiotic even though they usually have a viral illness."

The UpToDate review also looks at the associated issues of overprescription of antibiotics, the 20 year CDC initiative on antibiotic overprescribing that has essentially failed and the dire consequences of developing multiple antibiotic resistant bacterial strains.  My purpose here is not to imply anything about my treatment, but to illustrate that these practices are common and there is no equivalent amount of criticism similar to that targeted at psychiatric care.  In fact, if I wanted to take on the role of pseudopatient, I could walk in to any clinic or emergency department and walk out with the same prescriptions - even in the absence of acute bronchitis.  I could simply lie about the symptoms.  Nobody is going to ask me for a sputum sample, and 6/7 asthmatics have residual wheezing that can be picked up on a cursory exam.  Of course there would be public outcry.  I would be accused of lying to hard working physicians and wasting their time.  But that same poorly conceived idea is still cited as evidence against psychiatric diagnosis.

Unlike the unrealistic critics of psychiatry, my goal here is not to embarrass anyone, or illustrate that I am better than anyone.  But how is nonpublication of clinical trials of paroxetine (a drug that I have not prescribed in over 20 years) a problem with psychiatry?  Nonpublication of clinical trials is obviously a problem for everyone.  The poor quality of current clinical trials technology is a problem for everyone and unlike the Cochrane database, I don't see the point in the exhaustive documentation of predictable low quality results - at least not much of a point.

I am also not about to attribute the differences in practice and clinical trials to the art of medicine.  This is a problem of analyzing huge amounts of data in biological systems.  There are widespread problems with clinical trial design in every area of medicine because they cannot analyze that data.  Contrary to being a "gold standard" there needs to be better stratification of heterogenous diseases whether that is depression or bronchitis.  We can only have more specific treatments when we have better characterized molecular pathology and the treatments to target that pathology.  That includes markers that would suggest which patients would respond to drug treatment and which would not.  There is a promising biomarker for bronchitis that should be treated with antibiotics right now, but it is not widely studied or widely available.

The highlights of this post have really not changed since I began pointing out that psychiatry is singled out for criticism by various people with various motivations.  Looking at the facts in this post should leave little doubt that this is merely a continuation in this trend of unrealistic and unfair criticism consistent with the dynamic I outlined in the past.

Some things just don't change.


George Dawson, MD, DFAPA



References:

1:  Thomas M. File.  Acute bronchitis in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 23, 2015.)

2:  Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014 Mar 1;3:CD000245. doi: 10.1002/14651858.CD000245.pub3. Review. PubMed PMID: 24585130.

3: Riveros C, Dechartres A, Perrodeau E, Haneef R, Boutron I, Ravaud P. Timing and completeness of trial results posted at ClinicalTrials.gov and published in journals. PLoS Med. 2013 Dec;10(12):e1001566; discussion e1001566. doi: 10.1371/journal.pmed.1001566. Epub 2013 Dec 3. PubMed PMID: 24311990



Supplementary:

Graphic updated daily for the course of the illness:

This illness finally cleared at about Midnight on August 28, after 16 days.  The "common cold" typically lasts 2 - 3 weeks and is a significant cause of morbidity in this country.  I hope that I have also illustrated that it is also a problem in terms of treatment and a lack of real public health measures to reduce the spread of these viruses.

What Have I Learned So Far?

I started writing this blog over three years ago.  I decided to start writing it for a number of reasons.  First and foremost was the constant stream of inappropriate criticism aimed at psychiatry that contrasted with my real life experience working in the field and working with very competent colleagues in the field.  The second reason was to strike back at managed care and its various forms that I would include today as pharmacy benefit managers, government bureaucracies and even politicians.  All of the individuals and organizations continue to promote and institutionalize rationing strategies that are supposed to be "cost effective" but basically route hundreds of billions of dollars away from patient care to unnecessary business managers.  The third reason is the disproportionate impact that the first two have on patient care.  The care of patients with psychiatric problems has been decimated by this mindset that is both hypercritical but ignorant of psychiatric care and at the same time rationing the resources to the point that incarcerations are commonplace.  Even if a person with a serious problem gains entry into a system of care, there is no guarantee that they will receive any - as administrators with no expertise at all make critical decisions about whether they are hospitalized, whether they get detoxification services, what medication they take, how intensively they are seen in clinics, and whether they get the additional supportive services that they need.  A related fourth issue is that even though systems of care define "dangerousness" as essentially the only reason people need to be hospitalized these days, they do a very poor job of assessing and treating it.  It needs to be addressed at a public health level as well and aggressive and homicidal behavior associated with mental illness needs to be systematically addressed rather than being swept under the rug as "stigmatizing".  Teaching is something that I am good at and I take an informational rather than process based approach.  What I post here is more likely to be high in information content and unique rather than entertaining.  In that area, I have wide interests in the field and how they apply to patient care and theory.  I post some scientific articles and clinical strategies that I hope will be clinically useful by my colleagues and in many cases they have already been vetted by some of my fellow psychiatrists.  Human consciousness is a related issue that I think has essentially been ignored by modern psychiatry and some of what I post here are examples of consciousness and how it works - both my own and other peoples.  That is the basic matrix that I am working from.  Other points that I have observed and what might be useful information for other potential psychiatric bloggers follows:

1.  Nobody really cares about your blog:  Blogs are a dime a dozen and everyone writes one these days.  My initial goal was getting my viewpoint out if people are interested or not.  An additional corollary in psychiatry is that in order to maximize the readership, the odds are better if you are criticizing the field or provocative rather than debunking a lot of the unrealistic criticism.  I hope it is clear that I am writing no matter what and will keep doing that as long as I care about what happens to psychiatrists, physicians, and their patients and and I continue to know exactly what the problems are.  As far as I can tell - there is very little of that perspective available in the blogosphere, the press, or even the editorial section of professional specialty journals.

2.  Thirty years of practicing medicine saps your creativity:  Most physicians realize this, but I have not heard many actually come out and say it.  I was a fairly skilled writer at one point, at least according to my undergrad professors.  Tens of thousands of pages of medical documentation later, much of it meaningless bullet points added for administrative purposes that mind numbing exercise has taken its toll.  Most physicians consider writing to be a burden for that reason.  My prose has become obsessive at times and (thanks to the electronic health record) grammatically incorrect.  I have been fortunate to have a regular reader here send me corrections and ideas on how to improve and greatly appreciate that advice.  Medical schools select bright and creative people to become physicians.  When those same medical schools are unconcerned about a deterioration in the practice environment that stifles creativity and dumbs down medical practice they are doing a disservice to medical students who they select for those qualities.

3.  Ignoring the haters:  This has never been a really big problem of mine.  Once you discover that a substantial number of people dislike psychiatrists and their reasons are irrational, they are easy to ignore,  My only initial mistake here was allowing several of these posts onto my blog when I should have just rejected them all.  I have seen what happens to threads and blogs where this irrational corrosive opinion is allowed to persist under the guise of "freedom of speech" or "freedom to criticize".  Any collegial atmosphere that I have ever trained in allowed rational criticism delivered in a manner that was acceptable to everyone.  Any post sent in my direction that I don't think would fly in a meeting of physicians, will not see the light of day here.  A good example would be attempting to post that I am a "drug company whore."  That is inappropriate first and also wildly inaccurate.  Some of the most notorious critics clearly do not know what psychiatrists do and have glaring deficits in scholarship on the subject.  For those who are inclined to ethical arguments, I would argue that it is unethical to allow a serious discussion by trained medical experts to be disrupted by people who are basically there to be disruptive and have nothing else to offer.

4.  Ignoring the numbers:  It is always difficult to figure out what the Blogger statistics mean.  They vary by a factor of 10 on a day to day basis.  In some cases, I have gotten 900 page views in less than one minute and doubt those represent anything real.  In many cases, the referring URLs are clearly spam sites or originate in countries where the youth are encouraged to become hackers and steal money from foreigners.  There are the occasional referrals from sites that seem to be legitimate, like valid educational sites.  I don't get too excited about the statistics - aggregate or parsed.  Anybody reading this and having a sense of solidarity with my statements and goals whether they say so or not is good enough for me.

5.  Analyze the rhetoric:  One of the most consistent dynamics that can be observed is how the most criticized branch of medicine is handled with a total lack of accountability on the part of the critics.  They of course can say whatever they want to and often loudly proclaim this as their right.  There is an inevitable group of hero worshipers that back them up like they have some new insights.  In fact, they have a collection of vague and inaccurate observations that they cling to like they know something about medicine or science.  Some real experts uncritically lend credence to some of these off-the-wall ideas.  One of the leading authors in this area had his book endorsed by an editor who was herself very critical of psychiatry.  It doesn't seem much different than coalescing around the concepts of Intelligent Design.  No science or even rational analysis.  Only an understanding of rhetoric prevents one from falling into this trap.

6.  You can only save yourself and maybe your patient:  Much of the heat when it comes to psychiatric criticism flows from business and ethical problems with pharmaceutical companies and associated physician conflict of interest.  There are entire blogs where this seems to be the only topic of interest.  One of those blogs claimed that they were "keeping psychiatry honest."  The implied claim in these sites is that complete transparency of all drug trials and no contact between physicians and the industry will lead to a new idyllic state, where we will only have completely safe and effective drugs.  Maybe we will also be able to stop studying neuroscience and hearken back to the psychotherapies and psychosocial interventions of the 1970s.  Those ideas are so naive that I could barely stand to type them out.  That line of thinking completely ignores the corrupt elephant in the room (Congress) and the fact that the FDA is clearly politically influenced to the point that they can ignore the recommendations of their own scientific committees and put any drug on the market that they want.  It ignores that fact that American governments are pro-business to the detriment of the individual and that corporations readily accept the model of paying civil penalties as a reasonable risk for pushing the business envelope.  It also greatly ignores that fact that psychiatrists are really minor players in the pharmaceutical and medical device industry, but nobody in the press seems too worried about that.

7.  There appears to be little solidarity among physicians:  Physicians have been divided for decades now by splitting and political factors both between specialties but also within the same specialty.  I think that is part of what fuels the cultural norm of criticizing colleagues even though the vast majority do good work and have no apparent or appearance of ethical problems.  See my post on monolithic psychiatry rhetoric.  I think that the critical component of scholarship is also frequently ignored when some adopt the posture that any criticism is the equivalent of criticism from within the field.  To me that is a falsely modest position when you have been rounding with physicians who are clearly well read and have the associated clinical experience.  Medicine is not something that you can learn from reading snippets on the Internet.  I don't know if there is widespread knowledge that physicians are actively managed to maintain them in a fractioned state.  When productivity units were first introduced,  managers everywhere suggested it was because there was tremendous variation in productivity and some physicians were not pulling their weight.  After everyone was being measured and pilloried about their "production" every month, it was apparent that was a lie.  But what better way to foster an "every man/woman for themselves" attitude and destroy any semblance of professional solidarity?  Let me say this here for future reference, the "management" of physicians is really psychological warfare against physicians and the motivation for those strategies is varied but certainly not benign.

8.  An ethical climate is well ..... an ethical climate:  Part of the business of manufacturing news and headlines includes constructing an ethical climate and applying it to the people being criticized.  There are generally set-ups for provocative articles that seem scandalous.  In fact, most of the ethics is debatable and the debates are typically one-sided.  That is the best way to both win an argument and successfully smear an opponent.  There are many an ethical environments and straw men set up against psychiatrists.  If it is clear that a physician has broken the law or the medical practice rules in their own state that constitutes proof of wrongdoing.  I have lost count of the times I have referred people to the Medical Board when they were complaining about a physician.  That generally marks the end of the discussion.  Most seem to have the expectation that publicly shaming a physician through ridicule means something.  It doesn't mean anything to me.

9.  Physician professional organizations are weak and ineffective:  I am a 30 year member of the APA and AMA.  That does not prevent me from criticizing these organizations or recognizing their shortcomings.  Psychiatry organizations are no different than the AMA or other physician organizations.  They have been very ineffective in the area of mental health policy especially countering managed care tactics to ration and restrict care.  They no longer advocate for state of the art care.  As I recently critiqued their guideline, it was not clear that you had to be a trained psychiatrist to use it.  That said, they have supported a few good initiatives like banning the participation of psychiatrists in torture and the resumption of Clinical Guidelines.  I am committed to speak out against APA positions that I think are problematic like their support of the American Board of Psychiatry and Neurology (ABPN) position on recertification, collaborative care, the use of rating scales to establish quality of care parameters, and their participation with managed care entities to establish guidelines or quality parameters.  The APA has to do far more in establishing criteria for inpatient care of psychiatric and addiction problems and be actively critical of proprietary guidelines that facilitate the rationing of care.  But the commonest distortion is that the APA or the AMA have some kind of power to influence the politicians and businesses that run medicine in this country.  Nothing is farther from the truth.

10.  Developments in the field are important:  The psychiatric literature is better than it has been at any point in my lifetime.  There is a lot more to it than clinical trials and the current state of clinical trials seems like a dead end to me due primarily to a lack of sophistication.  Certain buzzwords like evidence-based medicine, controlled clinical trials, and collaborative care have been coopted by non-physicians to the point that they are often meaningless.   I critiqued a massive Medicare guideline that included a 40 page description of the evidence necessary for basic documentation.  In addition to the literature, there are excellent educational conferences widely available across the country.  People often lose sight of the fact that life is not a clinical trial, the clinical method is faster and probably safer, and that clinical trials both real and proposed are not necessarily the best use to time and energy.

11.  Trying to be creative:  Creative commentary and creative writing is possible and it is part of the tradition of psychiatry.  I have added a few things along the way that illustrate important concepts in a non-technical way and I am trying to add more graphics.  Some of these pieces are also there to illustrate stream-of-consciousness concepts - either mine or somebody else's.

12.  Supporting other bloggers:  I am quite happy to support other psychiatrists who are bloggers and any bloggers who I consider to be useful sources of information.  The blogosphere is immense and I am sure I have missed some people.  I try to include them in the list of blogs I follow and consult that list regularly.  If you are a psychiatrist, I encourage you to start your own blog, find your voice and add it.   I am very familiar with the work of hundreds of psychiatrists in the Midwest and know that my opinion reflects the opinion of many of them.  If your experience is my experience, you know that psychiatrists deal with impossible problems with minimal resources, put up with some of the most obnoxious administrators and managed care bureaucrats and we still get good results for our patients. Add your voice to the realistic information about psychiatry on the Internet and I doubt that you will regret it.

13.  Staying non-commercial:  Bloggers are encouraged to add on commercials and in some cases make money by blogging.  That seems like a potential conflict-of-interest to me, especially if you are marketing additional products like books, CDs, and speaker fees that espouse your personal viewpoints.  That is good because it may allow an appreciation of what it is like to attract paying customers including what needs to be said and the manner in which it is said.  It can also be a laboratory for the forces similar to the corrupting influences in the business world that can affect the delivery of health care.  Either way that is an influence on a blog's content.  Many posters seem to view blogs as their own method of advertising and attempt to design posts that bring readers to their own sources of advertising.  I think it makes sense to avoid avoid that advertising like you can avoid talking with pharmaceutical company sales staff and carefully consider what you are reading on a blog that is trying to sell you other products.


Paying attention to all of these things and more will hopefully keep me on track and keep me posting what is really going on in psychiatry as well as information that is useful to psychiatrists, other physicians, trainees, and anyone really interested in some of these topics.  I am not enough of a megalomaniac to believe that I can change the trends I am attending to, but I will not let them slip by without some realistic commentary.

That's about all I can say.


George Dawson, MD, DFAPA

Is It Time To Quarantine Air Travelers?

My wife and I just got back from Alaska on August 10, 2015 and within a few days became progressively symptomatic with an influenza-like illness that appears to be peaking today on day 5.  I know exactly how we were infected.  There were several ill passengers, particularly in close proximity who had not mastered coughing into the crook of the arm and who were actually coughing and sneezing over the top of the arm.  The plane was packed as usual.  We had paid an extra $100 to be able to sit in "economy comfort class".  In fairness there was about an extra 4 inches between my knees and the back of the seat in front of me (and I m 5'10'' on a good day).  Even that could not make up for the severe ergonomic problems of airplane seating.  I would quickly describe those as a lack of upright, even in the upright position.  Upright is at least 15-20 degrees from upright and over the course of a 5 hour flight that can create quite a bit of pain in anyone with a back problem.  This problem has been studied to some extent as evidenced by bullet point 3 on this web page.  The economy comfort class also comes with free alcoholic beverages, and I saw one passenger who was clearly uncomfortable rapidly down 4 drinks.  The other ergonomic problem is an ill defined seat.  It felt like sitting on 5 or 6 tennis balls all the way.

But back to the focus on viruses.  From discussing the problem with friends and family it is almost a universal experience that people get viral illnesses on their flight back from a recreational or work destination.

When I boarded a cruise ship recently I was screened for GI symptoms and asked if I had any recent illnesses as part of the check-in procedure.  That did not happen at any point when I got on either of the direct flight to or from Minneapolis.  In addition to the screening procedures there was hand sanitizer being actively and passively dispensed throughout the ship and on the ships TV channel the following message played continuously on a 24/7 basis:

Please wash your hands often and use the sanitizer stations provided throughout the ship especially when you are coming from ashore.  Always use a fresh cup when using beverage dispensers and refrain from using personal containers directly or on common beverage stations.  To stay healthy wash your hands with soap and warm water frequently.

 In comparing respiratory infections from air travel to Norovirus infections on cruise ships there are important differences.  The Norovirus infections occur in a well defined captive population in  very specific time period.  If an outbreak occurs it can become widely known, to the public relations detriment of that cruise line.  If a respiratory virus is contracted on a flight, everyone leaves the plane after arrival in a few hours and the total number of people infected is unknown.  There have been studies that look at the attack rates of people who have been on a flight where there is an index case of influenza and also the effects of using masks prophylactically when there are known index cases onboard.  There are no cautions to the passengers about how to prevent the spread of respiratory infections and (to my knowledge) no easy way for them to cancel in the event that they develop an acute upper respiratory in infection.  The CDC has some limited guidance on air travel, including some information on influenza transmission cabin air conditioning including the fact that it is partially recirculated and HEPA filtered 15-20 times per hour.  The most interesting study in microbial diversity in commercial aircraft that I could find was by Osman, et al (1) who compared conventional culture techniques to available molecular probes in 2008 in samples from 16 domestic and international flights.  They conclude that the molecular probe techniques demonstrated a much greater microbial diversity than culture techniques and that microbes varied significantly from domestic to international flights.  The molecular probe techniques identified 12 classes and 100 species of bacteria in cabin air, but in sufficiently low concentrations to not present a health hazard.  I am aware of studies in the past that have done viral cultures for respiratory viruses on filters in buildings but could not find similar data for commercial aircraft.  There have already been simulations about what happens when a person sneezes on an commercial aircraft, and those results are eye-opening.  I posted that in a look at the issue of hand washing and respiratory viruses.

Rather than go into excessive detail about the limited research that has been done so far, let me summarize a few facts and my conclusions.  Respiratory viruses can be transmitted during commercial air travel.  The attack rate for influenza virus has been estimated to be 2 - 4%.  There has been at least one study that shows masks can prevent infection.  There have been several simulations of how air travel potentially increases the world wide spread of airborne viral infections and some of these infections like corona virus and SARS outbreaks puts a significant burden on the international public health community.  Furthermore, the public health burden in terms of both morbidity and mortality is huge.  Influenza virus alone kills about 20,000 people annually in the United States or the equivalent of 5 large cruise ships in terms of total lives.  By comparison, there if far more press coverage of a Norovirus outbreak on a cruise ship and that virus is much less fatal.  Every American contracts about 2 - 3 respiratory viruses per year of varying severity.  That probably amounts to about 2-6 weeks of illness per year, associated with a disruption of work and daily activities as well as increased infection risk for those in the sphere of that person's routine.  There is also a risk for exacerbation of chronic illnesses like asthma and chronic obstructive pulmonary disease.

All of these considerations lead me to suggest (at the minimum) - the following measures:

1.  Intensification of study of airborne diseases especially respiratory viruses:  The technology is certainly there and there is no reason that molecular technologies cannot be applied to samples from commercial aircraft and I think that the HEPA filters are a logical place to start.  I would really like to see this become a focus of a private research fund, because it seems like the federal government has created numerous monitoring systems but no practical ways to detect high risk scenarios and disrupt disease transmission.  It seems like that is likely to occur only after an outbreak of a highly fatal respiratory virus occurs.

2.  Passenger education is critical:  The airline industry needs to adopt the methodologies that are currently employed in the cruise industry - educating everyone on the plane, screening for passengers at risk and quarantining them if necessary.  A critical piece of the education process is that while hand washing is necessary, it is not sufficient to prevent the spread of airborne respiratory viruses.  That public needs more awareness of that concept and what else can be done.  The method of quarantine is debatable and would probably need some flexibility based on passenger needs and acceptability and the severity of the problem.  It could include grounding until the infection clears, use of masks to block airborne infection, or possibly a section of the passenger cabin with more intensive HEPA filtering (altering air flow and humidity can affect the likelihood of virus transmission).

3.  Developing a culture to reduce the risk of respiratory virus infection:  Everywhere that I look we have practices in place that encourage the transmission of respiratory viruses.  Most Americans do not let respiratory viruses stop them from carrying on their business as usual.  In the past few days, I have personally walked through clouds of sneezed droplets because I happened to be following a fellow customer or coworker too closely at the wrong time.  I can't recall exactly when it happened, but getting rid of sick and vacation time and replacing it with paid time off or PTO days is an incentive for going to work sick.  Most of that sickness is respiratory viruses.

The American attitude to the common cold is far too casual.  It does not take into account the spectrum of symptom severity and the fact that many of these viruses can cause influenza-like illnesses and very severe syndromes.  Even a cold of moderate severity generally curtails a lot of activities and produces significant morbidity.  I don't understand how the medical and consumer community has come to this level of acceptance and denial of this collection of more-than-just-a-nuisance pathogens, but I would like to see it stop.

The American attitude toward the bad ergonomics of airline seating is another issue.  I think it is unfortunate that most passengers these days have never flown on a 747.  I may be overidealizing the flying of my youth, but planes today seem like dismal narrow aluminum tubes by comparison.



George Dawson, MD, DFAPA



References:

1: Osman S, La Duc MT, Dekas A, Newcombe D, Venkateswaran K. Microbial burden and diversity of commercial airline cabin air during short and long durations of travel. ISME J. 2008 May;2(5):482-97. doi: 10.1038/ismej.2008.11. Epub 2008 Feb 7. PubMed PMID: 18256704.

Supplementary 1:

For a graph of the URI I contracted on the Alaska vacation and most likely on the flight home follow this link.


Attribution:

The graphic at the top of the blog is directly from the CDC and one of their pages on Middle East Respiratory Virus Coronavirus.  Photographic credit is given to Jennifer L. Harcourt.  The picture depicts coronavirus particles in the cytoplasm of an infected cell.

Regret

If you talk with people experiencing anxiety and depression for any length of time, one the the common recurring themes is regret.  Regret is one of those complex psychological dimensions that spills over into everyday life.  It is a significant disappointment somewhere on the trajectory of life associated with negative emotions.  It is such a common experience that friends and family members will sometime talk about their regrets, or the regrets of another friend or family member.  It is a universal human experience that can make you sad or anxious and also amplify those emotions when they are part of a more phasic mood disturbance.

In the above classic movie scene a young Marlon Brando playing Terry Malloy, a dock worker who is dealing with corruption and crime in that setting.  He had been a promising boxer until his brother Charley in this scene (played by Rod Steiger) convinced him to throw a fight in order to favor Charley's boss at the time.  Charley is also trying to dissuade Terry from testifying against that same boss in this scene.  Those are parts of a more complex plot, but it contains all of the detail that is relevant as Terry and his brother discuss the incident in this famous scene.  Terry seems to be expressing regret at two levels - one for throwing the fight and the effect it had on his reputation but more importantly for having an older brother who does not look out for his best interests and does not treat him well.  Charley seems to be treating him well in this scene only as a form of bribery.  He is offering him a paying job only to buy his silence.

People tend to regret a lot of things in the course of a lifetime - lost relationships, past behavior, missed opportunities, repetitive patterns of behavior that they don't seem to be able to break out of, and in some case entire periods of their life.  Common examples from the late teens to young adulthood include missed opportunities in relationships, school, and work.  It is very common to hear people complaining that they regret not applying themselves in school.  In some cases they regret choosing a particular career path and worry about whether it is too late to change.  There are myriad regrets possible just considering the family structure and the emotional reactions and expectations that people have of one another.  It can be combined with blame as in: "I wish you would have forced me to keep up those piano lessons."  At times people predict what might lead to regret in the future.  A common prediction is: "Your grandparents are not going to be around forever.  You might regret not going on this visit to see them."  In this era of social media, there are always posts about what you will regret on your death bed.  Apparently it won't be not spending enough time at work.  When I was a junior in high school, one of my friends predicted that I would regret not going to the prom.  In the decades since, I have had very few thoughts about high school and none on that dance.

One of the many questions that I find myself pondering in my down time is;  "What is the best conceptualization of regret?'  What is the best way to make sense of it?  What is the best way to adapt to it?  Does it make sense to think about getting over it?  At one point in my early 20s,  I took a harsh approach to some emotional thought patterns that could be troublesome.  My credo became "No guilt, no shame."  I started to spread the word.  I encouraged people to be proactive which is really the best approach.  If you make decisions on a daily basis that will not result in guilt or shame, what could be better?  No regret would be a welcomed by product.  Of course there were sacrifices along the way - spontaneity and risk taking being a couple of good examples.  You run the risk of being a "stick in the mud".  There is also the very real issue that you can just be wrong and despite your best intentions there are regrets along the way.

Regret is one of those concepts that seems to crossover from psychiatry to literature and English professors may do  better job of analyzing and appreciating it.  In Moby Dick, Melville introduces Captain Ahab's family in order to point out the contrast between an obsessive, all consuming pursuit of the white whale and time spent away from his family.  After casting a single tear of regret into the sea, a tear described as in the following passage:

"From beneath his slouched hat Ahab dropped a tear into the sea; nor did all the Pacific contain such wealth as that one wee drop."

Ahab launches into this soliloquy that is an ode to regret:  "Oh, Starbuck! it is a mild, mild wind, and a mild looking sky.  On such a day—very much such a sweetness as this—I struck my first whale—a boy-harpooneer of eighteen!  Forty—forty—forty years ago!—ago!  Forty years of continual whaling! forty years of privation, and peril, and storm-time! forty years on the pitiless sea! for forty years has Ahab forsaken the peaceful land, for forty years to make war on the horrors of the deep!  Aye and yes, Starbuck, out of those forty years I have not spent three ashore.  When I think of this life I have led; the desolation of solitude it has been; the masoned, walled-town of a Captain's exclusiveness, which admits but small entrance to any sympathy from the green country without—oh, weariness! heaviness!  Guinea-coast slavery of solitary command!—when I think of all this; only half-suspected, not so keenly known to me before—and how for forty years I have fed upon dry salted fare—fit emblem of the dry nourishment of my soil!—when the poorest landsman has had fresh fruit to his daily hand, and broken the world's fresh bread to my mouldy crusts—away, whole oceans away, from that young girl-wife I wedded past fifty, and sailed for Cape Horn the next day, leaving but one dent in my marriage pillow—wife? wife?—rather a widow with her husband alive! Aye, I widowed that poor girl when I married her, Starbuck; and then, the madness, the frenzy, the boiling blood and the smoking brow, with which, for a thousand lowerings old Ahab has furiously, foamingly chased his prey—more a demon than a man!—aye, aye! what a forty years' fool—fool—old fool, has old Ahab been!......." (Chapter 132).

His chief-mate Starbuck tries to talk him into ending the pursuit, but we all know how that turns out.  Even world class regret does not necessarily lead to self correction.  Similar statements cut across clinical and non-clinical settings.  I don't consider regret to be a symptom of any psychiatric disorder per se, but it will typically make things worse and in some cases be an unexpected point of focus.  What might be useful points for discussion?  A standard supportive approach would look at how human consciousness operates.  Whether you are a boy harpooner of 18 or a prize fighter in your early 20's, you are likely to make decisions at those times in your life that will not be the same decisions that you make 5 or 10 or 20 years later.  Eighteen year olds are energetic, eager to prove themselves, at their physical peak, and to a large degree see themselves as being invincible.  They are bound to make decisions much different than a 60 year who has battled life for 40 years and is left feeling spiritually withered.  Not being the same person at 60 as you were at 18, is not necessarily that intuitive in areas of life apart from the physical ones.  I think it illustrates that the situation remains dynamic and there is no reason to expect that different decisions can't occur.  In modern society, the decision to retire is a key decision that activates some of these thought patterns and associated regrets.

Physicians are professionals with some of the highest degree of regret.  There is the phenomenon of physician burnout fueled largely by the fact that they have limited control over what happens in clinical settings and that the people with more control don't know anything about medicine.  Many of the burnout surveys have to do with regret about going into medicine.  But there are also the inevitable mistakes in patient care.  I heard a neurosurgeon describe some of his regrets on public radio including a case where he tried to resect an additional amount of tumor that resulted in the patient being in a persistent vegetative state.  I was personally in a discussion of a transnasal resection of a growth hormone secreting pituitary adenoma that was wrapped around the internal carotid artery. The discussant was a neurosurgeon who had probably done more of this procedure by far than any other surgeon in the world.  That discussion went something like this: "This is the tumor and this is the artery (pointing to areas on an MRI coronal view of the pituitary gland and sphenoid sinus).  I am going to try to remove as much of the tumor as possible.  If I accidentally nick the carotid artery in this area, there is nothing that can be done about it.  That complication happens and I know good neurosurgeons  who have had that happen to them.  I can assure you I will remove only as much tumor as possible.  I will remove only as much as I would remove if you were one of my family members."  Since I heard that conversation, now 6 years ago, I have come to realize that it was more than just an informed consent discussion of the worst possible complications.  It was also a way that this surgeon had learned to set limits on himself and the drive to completely remove a tumor, even at a point where the risk may be  increasing exponentially.  I have seen good physicians who approached medicine as a science, who were not able to adapt to the inevitable mistakes or adverse outcomes.  Many ended up paralyzed with regret and needing to take time away from the field.  Some left for good.  I don't think we do a very good job with medical students and trainees in helping them develop a realistic view of the field.  A view that might temper them against the inevitable regrets.

As psychiatrists, we all need the vocabulary for discussing regret with our patients, because it is one of those things that crops up and takes over an appointment scheduled for another purpose.  We suddenly find ourselves in a supportive or psychodynamic or cognitive-behavioral or mindfulness mode dealing with the crisis.  Everything we had planned to do in that session, including assessing the patient's progress with their primary problem has gone out the window.  More importantly regret is part of life and not an error in thought or emotion.  Normalizing that experience will go a long way toward helping the person in crisis.

  

George Dawson, MD, DFAPA

Refs:

Herman Melville.  Moby-Dick or the Whale.  Project Gutenberg EBook.  Originally published in 1851.

Attribution:

The graphic of the original cover of Moby Dick is from Wikimedia Commons with the attribution line.  It is in the public domain:

By The original uploader was Chick Bowen at English Wikipedia (Transferred from en.wikipedia to Commons.) [Public domain or Public domain], via Wikimedia Commons.

The New APA Practice Guideline

I got a link to the new American Psychiatric Association (APA) Practice guideline today in my Facebook feed.  It was entitled Practice Guidelines for the Psychiatric Evaluation of Adults.  It is an updated version of a previous guideline by the same name.  I have pointed out on this blog that the APA seems to have all but abandoned the production of these guidelines with the exception of some extensive work for CMS to determine whether or not administrative guidelines about billing and coding were adequate.   When I complained to APA officials about the fact that they were not producing any new or updated guidelines I was told two things.  The first was to wait for this current guideline.  The second was that guideline production and updating did not seem to be a wise use of limited resources.  My interpretation of that remark was that it was defeatist and probably related to the fact that everyone is currently producing guidelines.  I guess that nobody at the APA recognizes the need to set limits on pro-business and pro-government guidelines that actively discriminate against psychiatrists and their patients.  Apart from a single APA President, that seems to have been the conventional wisdom that they have been using for the past 30 years.

I read the entire relevant section of the Guideline and that involves the first 52 of 170 pages.  The last section includes references, abstracts and methodology like bar graphs showing how many experts agreed that a certain type of assessment needed to be done in an initial assessment.  The introductory release explained that the guideline was based on an Institute of Medicine (IOM) publication entitled Clinical Practice Guidelines We Can Trust.   I have not been impressed with some of the work done by the IOM in the past and after reading three of their previous books wonder if it makes sense to read a fourth.  There are additional references on the methodology in the introductory sections of the document.  The release describes the guideline as modular so that each of the nine different modules can be updated regularly and separately.   That is a good idea that will hopefully add timeliness to the process.  One of the goals is to have the guideline widely disseminated.  Apparently anyone can download the document and read it.  There are the usual legal qualifiers pointing out the limitations of a broad document like this one and why it cannot be considered a standard of care.  I did not see the most obvious reason mentioned and that is that this concept is a legal one used for the determination of medical malpractice and that it really has no application in medicine.  Guidelines are referenced in Gutheil and Appelbaum's text:  "Third, another source of information about standards of care is the growing number of practice guidelines.........  It must be remembered, however, that even well-designed guidelines  do not necessarily address all possible approaches to a clinical issue." (1).  So the guideline disclaimer is clearly debatable in court.

As I read through the guidelines several things jumped out at me.

1.  It was not clear that this guideline was written for psychiatrists -  Some may say that this is implicit, but I am bothered by the fact that in the first 52 pages the word "clinician" pops up 34 times and the word "psychiatrist" pops up 17 times.  What would prevent any clinician from claiming that they have done everything listed in this document and therefore their evaluation is the equivalent of a psychiatrist's evaluation.  This is more than a guild or political issue as I will elaborate below.

2.  It was not clear what type of expertise was necessary to use the guideline - I suppose this is a minor variation of the first point, but technical expertise to me has always been a critical issue.  The guideline gets around this by saying it is not a "comprehensive" document.  I would not consider the recognition of acute medical and neurological problems or even chronic ones to be beyond the scope of a psychiatric evaluation.  I would not consider an abbreviated list of these conditions to necessarily render this a comprehensive document and it would certainly have more clinical value than a tedious list of all of the survey results.  The document also discusses tests in terms of the optimal ordering of tests and also specific kinds of tests.  What about who interprets those tests?  As a very basic example, I would go back to the days of the oral board exam in psychiatry and frequent questions about the use of lithium.  Board examiners were interested in what tests needed to be ordered to initiate and follow lithium maintenance therapy.  The goal of that exercise was to certify a safe practitioner of psychiatry.  In today's world, there is a much larger number of tests, interpretations and plans based on those tests.  This is a critical line of demarcation in some practice settings that seek to limit the medical role of psychiatrists.

It is apparent that the APA wants this guideline to be widely disseminated.  A related concern is that they may have not learned much from the wide dissemination of the DSMs over the years.  Although there is a partial financial incentive with DSM releases, the APA may be oblivious to the downside of everyone having a copy of this manual.  The pre-DSM-5 release rhetoric illustrates that a lot of critics had a very poor understanding of what the DSM-5 was and how it would be used.  Wide dissemination of a vaguely written practice guideline may have the same effect.  There is a common bias than anyone with a social brain who can speculate about the motivations and goals of others can do what psychiatrists do.  There are endless examples of various writers speculating about which public figure may have Asperger's or narcissistic personality disorder.  The sentiment in some circles seems to be: "If I have a copy of the DSM - I can diagnose people."  What is to prevent a similar co-opting of the Practice Guideline?

3.  There is nothing really surprising in the document - The assessment techniques are either obvious things that psychiatrists and psychiatric trainees do on a regular basis.   There are so many qualifiers that many approaches can be taken.  For example, the issue of coming back to an initial point to clarify the diagnosis if it could not be appropriately done in the initial interview was mentioned several times.  That is useful in cases when a patient is embarrassed or defensive about a particular aspect of their history.  In this regard, the document represents both content and process variables of the interview.  

4.  Tip of the cap to evidence based medicine - even when it is not needed - A common refrain throughout the guideline was:  The strength of research evidence supporting X is low, where X is the guideline of interest.  I summarized the guidelines and statements in the table below.  The numerical and letter designations can be translated as follows.  The numeral 1 is a recommendation.  The numeral 2 is a suggestion.  The letters A, B, and C are degrees of evidence reflecting high moderate or low degrees of evidence respectively.  The table basically reads as a recommendation or a suggestion backed by low degrees of evidence.

Using research evidence as a criteria for standard clinical methods is taking evidence based medicine to its absurd conclusion.   I am not talking about refinements in the way the history and physical has been done over the years, but the basic idea that a physician has to make a diagnosis and come up with a treatment plan.  Is there really any question that there are currently thousands of clinical trials that document positive treatment effects based on inclusion criteria that include a standard evaluation of the patient and the recognition of certain medical exclusion criteria?  The Guideline includes an explanation about why it is unethical to do certain double blind placebo controlled trials such as the study of suicide and aggression.  It does not comment on the important clinical question: "When does the anecdotal become statistical?"  To illustrate, if I am currently an inpatient psychiatrist and 100% of the patients I see are admitted for suicidal/aggressive ideation/behavior and my post discharge complication rate is very low (1 incident of suicidal or aggressive behavior every 500 discharges) - what is the likelihood that I am no more effective than placebo?  Do I really need a clinical trial to prove that I am doing something?  Are there any statisticians out there willing to speculate on that problem?    

5.  The information aspects of the evaluation - this critical aspect of the evaluation has not been studied in the field and the lack of these studies leads to a number of vagaries in the guideline.  It should be possible to illustrate the range of information exchange across a number of interviews and the optimal amount of information exchange in terms of diagnostic yield and enhancing the diagnostic and therapeutic aspects of the interview.   It is a way to advance the technical aspects of the field without deference to neuroscience.  Psychiatry has been stuck in essentially the same interview technology since the 1940s with no significant advances.  Looking at the information exchange that occurs in the interview is a long standing omission and it is probably the best way to advance this central part of clinical practice.

6.  A well deserved shot at the electronic health record  - After about two decades of hearing nothing but praise for the EHR and how it will revolutionize the practice of medicine and "save" us all hundreds of billions of dollars, its shortcomings are so obvious and so severe that even the APA gets it.  From page 44 of the Guideline:

"With the increasing use of electronic record systems, the structured but fragmented information that is common in electronic record notes can increase cognitive workload and reduce the quality of communication among those caring for the patient..."

That is a diplomatic way of saying that if you follow the suggestions for collateral information in the Guideline and are unfortunate enough to get either a printout or have direct access to an EHR, you might spend hours reading through hundreds of pages only to discover that the document has no discharge date, that it contains minimal information or that (in the case of lab testing) you can't determine the dates that any of the testing was done.  You will probably also encounter an EHR template approach to documentation that provides a series of "yes-no" responses where real information is traditionally used.  The current EHR is a plague on those specialists who require high quality information and plenty of it.  It should be apparent from the general requirements of this guideline that psychiatry is at the top of the list.

7.  Inconsistencies are present in many places - One of the better examples is several qualifier paragraphs that point out how descriptions may be necessarily vague and how to negotiate that in the assessment itself.  There are terms having to do with time as well as clinical descriptions.  The guideline says that it does not encourage stereotypical questions to complete the assessment, but at the same time suggests "quantitative measures" like standard checklists.  I cringe when I see that term because it was a term that was included in the Joint Commissions 2000 statement on pain assessment and treatment and we all know how that turned out.  To an old chemist, asking a person where they are on a ten point scale that rates pain or depression or anxiety is far from a quantitative measurement.  At some point, psychiatrists and physicians lost sight of the fact that certain organ systems (the brain in particular) by its very structure,  precludes quantitative analysis - and that is a good thing.  The authors of this guideline should at least attempt to explain how an obviously subjective and flexible evaluation can eventually lead to rigid "quality" measures that are also being used as if they are quantitative.  At some point, some professional organization needs to point out that most if not all of these measures are fabrications of the business community and government and they have little to do with medicine or science.  If the APA can say that about all of the points in their guideline, why can't they point out that the same "quantitative measures" are used in collaborative care and they mean the same thing.

8.  The serious dimension of the diagnosis - There are a lot of reasons why patients and families tend not to take a psychiatric diagnosis as serious as they should.  It took me a number of years in clinical practice before I realized that any informed consent discussion I have with a person should include whether or not that diagnosis is life threatening to them.  In some cases like talking with a survivor of a near lethal suicide attempt it is obvious.  In other cases like a major psychiatric disorder and a number of close calls due to a substance use disorder, it is less obvious.  I will tell a person that the condition they have is life-threatening and the treatment plan and their part in the overall treatment needs to take that into account.  There may be an associated discussion of voluntary and involuntary treatment as well as a clarification of my position in the patient's treatment and the associated rationale.  I think it is critical that this assessment is made and carefully documented for continuity of care purposes.

These are a few of my initial comments.  The new treatment guidelines is far from perfect but it is a start to get the APA back on track again to establish reasonable guidelines written by psychiatrists about the practice of psychiatry.  The introductory material suggests that the method will be to modify the various sections, but what is needed is another section or probably a new guideline on treatment planning and how that interfaces with the Evaluation Guideline.   

George Dawson, MD, DFAPA

1:  APA Work Group on Psychiatric Evaluation.  The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults — Third edition.  American Psychiatric Association, 2015.

2:  Thomas G. Gutheil,  Paul S. Appelbaum.  Clinical Handbook of Psychiatry and the Law,  3rd Edition.  Lippincott, Williams, and Wilkens, Philadelphia, 2000. p. 299.      

A North American Cruise

Not going on a cruise was a always a high priority on my bucket list.  I am reporting that (for many reasons) I have failed in that pursuit.  My wife and I just got back from an 10 day excursion into Alaska by sea and out by land.  The first leg was a 6 day cruise from Vancouver, British Columbia to Juneau, Alaska and overland from there to Denali (Mt. McKinley) and back to Anchorage with a direct flight back to Minneapolis.  I started typing this as we left Ketchikan, Alaska headed for Icy Straight Point, Alaska. There is a mountain range silhouetted by the sunset outside my window.  The shore line seems to pass by at a rate much faster than the reported 16 knots, but that is not bad for a vessel weighing 93,000 tons.

Cruise ships these days are engineering marvels.  The one that I was on was 11 stories high.  It had a walking/running track on the top deck (200 meters/lap) with extensive spa and gym facilities.  The technical details of this ship are hard to find, but a little research showed that it was powered by 2 x 19 MW azimuth thrusters rather than propellers.  That explained the easy maneuverability of this nearly 1,000 ft long ship.  In front of the Hubbard Glacier, the captain was able to spin the boat in a circle for a couple of revolutions.  Sitting on the aft deck, the propulsion units have enough thrust to create prop wash that extends to the horizon.  A tour of these capabilities and the engineering involved would have been fascinating (for a few of us) but I understand the security constraints.

In the 5 months leading up to September each year about a million cruise ship passengers make this journey. As a psychiatrist who likes to keep track of cultural phenomena, this was one that I had missed.  The ship lines involved have created ports along the way with excursions to highlight the area resources and make the natural attractions readily available to a number of interests. A few examples include excursions into the world’s largest temperate rain forest capped off by a meal of fresh Alaskan crab. On that excursion today I learned some interesting facts. Ketchikan and the surrounding area on the island have a total population of about 10,000 people during tourist season, but when that is over the whole lower town built around the cruise industry shuts down and many people leave until next year. It rains almost 7 days a week in Ketchikan and the total annual rainfall is about 13 feet. One of the natives told me that people need to take Vitamin D and volunteered the typical dosing ranges of 2,000-5,000 IU per day. Some of the outliers were taking 10,000 IU. She said nothing about levels being drawn or cases of toxicity. The weather for this cruise was outstanding - generally sunny with temps in the 70s except for the period next to the glacier.   The town itself seemed to be organized like many small American towns.  The government buildings and fire department were most prominent.  I wondered what it might be like to be a psychiatrist in Ketchikan.  But I did not have too long to think about it, because in 4 hours we were back on the boat headed for Icy Straight Point.

In the meantime, I am nearly at the 50 day point of walking about 12,000 steps per day.  I decided to head up to the running track on the 11th floor of the ship and cover some ground.  This is the third day I am doing it.  There are a lot of people huddled in deck chairs in the bright sunlight. Even though the air temp is in the high 50s to low 60s, there is a stiff breeze blowing directly over the bow.  The only reasonable wear is heavy fleece or a windbreaker and a sweater.  I decided to sample my fellow passengers as I walked using an old survey method from wildlife biology.  From a demographic standpoint about 25% of the population was less than 40 years of age and half of that sample was less than 18.  At one point the cruise line had a special activity for the younger adults. Despite the age structure of the crowd, in the warmer climate pulling out of Vancouver, there was a steady loud beat of dance music on this deck, all compiled by a young disk jockey.  With this mix of ages there are always a number of clashes between the generations.  The energetic 10-15 year olds running randomly around the deck among the older folks.  A few grumbling old folks commenting negatively on the number of tattoos, especially on younger women.  Tall, thin, spectacled and silent post-adolescent girls are walking around in Converse high top basketball shoes.  Boys in that same age group are swaggering, swearing, and discussing Ivy League fashion.  The majority of the crowd was older and very well mannered.  There were a couple of groups celebrating anniversaries and weddings.  I had learned from another physician from a similar cruise that there were several people who required dialysis and there was a nephrologist on board to monitor that treatment.  The place was crawling with extraverts.  At times it was difficult to avoid conversations.  I saw a fellow introvert bundled up on a deck chair, facing away from the crowd and reading a book in the bright sunlight.  I could feel his pain.

Like most inescapable public gatherings the cruise creates quite a bit of tension within me.  At one point in my life I was a very active outdoorsman.  I was a tree hugger of the highest degree.  I was a white water kayaker and canoeist.  I nearly drowned three times in one day on the Montreal River in Upper Michigan and went back for more white water kayaking after that.  But at some point, all of that changed.  The landscapes seemed to be the same.  Hawaii was like Wisconsin with volcanoes. Colorado was like Wisconsin with mountains.  The terrain always looked better on television.  Alaska present thousands of miles of coastal mountains, some of which have the highest number of peaks greater than 10,000 feet of any mountain range in North America.  The glaciers were also unique, especially glaciers coming right out to the edge of the ocean, breaking off and creating waves, ice floes, and icebergs.  The ship navigated right into this area among the chunks of ice and spun around a few times before heading to Seward.

Polychrome Pass - Denali National Park

In everyday life I am still out there and very active, but the conditions have to be right and I have to be able to measure everything – miles, heart rate, cadence, speed, and all of the derivatives.  I avoid the hours from 10 AM to 3 PM or whenever my shadow on the ground is shorter than my actual height – a standard Dermatology tip on avoiding skin cancer.  I am no longer cycling in the rain.  The goals were more complicated.  I can no longer go out in the woods and plant trees with a grub hoe ignoring the biting flies and mosquitoes.  The parallel dimension was the demands of inpatient psychiatry.  There were decades of complicated problems, no solutions and confronting aggression and hostility at all levels on an almost daily basis.  I lived to go home, shut the door and enjoy the solitude.  Being stuck on a cruise ship where nearly everyone is an extrovert and trying to engage me in conversation is the antithesis of the last 25 years of my existence.  I am quite happy to be ignored but on a cruise ship it is common to encounter at least 10 crew members all of whom meet you very cheerily and begin with some variation: “Good morning sir. How are you today? Can I help you with anything?” I am sure that is standard cruise training is designed and implemented by extroverts.  Extroverts seem to dominate the customer relations fields and that’s why there is all of this unnecessary talk.  If I was consulting I might suggest an I (Introvert) Badge that translates to “You don’t have to ask me – if I have a problem I will ask you.” Or in the case of extreme Introverts “You don’t have to greet me – we are cool and I don’t think I am better than you.”

The entire cruise atmosphere was a study in contrasts for me.  On the one hand we were cruising through some of the most desolate places on the planet, ideal turf for introverts wanting solitude.  On the other we brought a party with us and even a party director who seemed bent on providing the maximum number of activities and entertainment per day.  That led me to think about people who might be stressed by the cruise.  Did anyone have anxiety or panic attacks?  I never made it down to talk with the ship's doctor about those problems, but it was easy to see how they might occur.  I also had the thought about people getting on the boat who were already depressed.  Would it lead to any adverse outcomes.  According to Wikipedia, there was at least one reported incident of a person who had gone missing on a cruise and who was seen jumping overboard when the security camera footage was reviewed.  I could find only one article on this phenomenon in Medline.  There is an associated literature that suggests that the mental health of seafarers in general, but primarily on merchant ships, may be poor as evidenced by suicides as a percentage of total deaths or deaths due to illness.  That author also suggests the numbers may be significantly higher if disappearances at sea are counted.  Suicide was also a topic during the tour.  Our tour guide said that Alaska had the highest suicide rate among the 50 states.  According to the CDC that is not strictly true but they do have the second highest rate at 23/100,000 or roughly double the age-adjusted suicide rate for the entire country.  They also have ready access to firearms.  Any Alaskan can carry a firearm concealed or unconcealed without a special permit.  One of our guides took a temporary break from the work to do a stint transporting mentally ill Alaskans to hospitals for treatment.  At this point, I can look back and see the opportunity to do a lot of good in Alaska if you are a psychiatrist who likes winter weather and are motivated to the point where you don't need a lot of collegial support.  But it is definitely a job for a younger person than I am.

Food is always a big point of discussion on cruises.  I can understand the advantages of not having to purchase or prepare it.  But the usual commentary is on how abundant it is and how good it is.  I am a very finicky eater and give it mixed reviews.  It was clearly abundant with large cafeteria style dining available all day long.  There were typically many entrees available followed by many deserts and pastries.  There was an ice cream bar and other specialty (pasta, eggs Benedict, pizza) stations on the side.  Food consumption there was unlimited and there were no additional charges.  You just walk into the cafeteria as many times a day as you like and you don’t have to pay anything for food.  In addition, there were two formal dining areas that needed reservations with more limited but high end entrees and appetizers.  Food consumption in those venues was limited to the standard restaurant style meal at no additional charge.  Finally there were four more restaurants that required additional payment for additional high end cuisine with consumption limited to that meal.  Beverage packages required the use of a pass card and prepayment of various beverage packages.  It should come as no surprise that cruises are risky for people trying to control their weight.  Before getting on this cruise a coworker told me that when her mother came back from a cruise she was almost “unrecognizable” due to weight gain.  Unless there is a conscious plan to limit consumption and exercise weight gain must be the rule on most cruises.

As far as the quality of the food, I give mixed reviews.  I am not much of a carnivore, but I do consider myself to be an expert in breakfast type foods, pizza, pasta, chicken, fish, and desserts.  If I compare the meals from the specialty sit down restaurants with restaurants within a 10 mile radius of my home it is clearly inferior.  That is not to say it was not good, just not excellent.  Almost everybody on a cruise raves about the food.  Their opinions may be biased by the overall cost of the cruise, the emphasis on food onboard (galley tours, discussions with the chef, wine tastings, etc), availability to well past the satiation point, and the ease of availability by no acquisition or preparation time by the onboard guest.  In addition, one of the few consistent television programs available onboard was Top Chef and it was on 24/7.  It has been trendy in the press to slam Americans for gluttony and obesity, but I won’t go there.  About 90% of the guests were Americans and Europeans from various ethnic origins, followed by Asians from various countries and then guests from Spanish speaking countries.   The cuisine was a mixture of American, Thai, Indian, and Japanese foods and it got good reviews from people originating from those countries.   I don’t think anyone was in an eating frenzy, just consistent consumption.  The majority of the food selections were very healthy and the main problem for consumers was portion control and limiting carbohydrates.

Alcohol consumption also seemed well controlled.  There were hierarchies in the beverage packages, most cost for the high end package containing alcoholic beverages.  There was a shopping area that sold expensive alcoholic beverages in large bottles with a duty free advantage, but I never saw anyone in that shop. Most of the drinking occurred in the deck and spa areas and with meals.  There was a meeting listed for anyone who was a friend to Bill W.  That may not be the rule on all cruises.  I listen to a morning talk show on the way to work and heard that the people on that show were aware of some "rock and roll" cruises that needed to make extra stops to pick up more alcoholic beverages.  This was a cruise that seemed to target families and multiple generations.

There is a curious tradition of formal dining that persists to this day.  I have been told that early cruises had assigned seating in the dining areas and at times that involved eating with the captain.  In those days everyone had to be dressed formally for it – for men that meant a sport coat and tie.  That tradition persists today but only on 2 days of the cruise.  It seems an unnecessary artifact to me.  The captain doesn’t eat with the guests.  I was told by one of the crew that they believe it encourages more socially appropriate behavior and a classier atmosphere.  My guess it that it probably has no more impact than the “no shirt, no shoes, no service” rules posted in various part of their literature. The extra attire takes up valuable room in the suitcase of nothing is really added.  My guess would be that all of this window dressing is the work of Extroverts (“Isn’t dressing up in formal attire fun?”).

After looking at a number of other comparisons like entertainment, electronic devices and Internet access, total cost of the cruise and associated excursions – I realized that an obsessive approach could be taken in the analysis. There are several web sites that take this approach.  The overriding question for me was what are the real differences between people who like cruises and people who don’t.  Whenever I give my opinion there is a general outcry that I am unreasonable and that my wife is a saint for putting up with me.  How could I not like a cruise?  And like most things it is a question of preferences.  My preference for eating carbohydrates dates back to an early age and I know the correlates and I think I know how all of that works at some level.  I also realize that those same mechanisms can produce preferences in billions of my fellow humans that are not my preferences and in this case it means that (at least on the surface) many more people seem to prefer cruises more than I do.



George Dawson, MD, DFAPA


Supplementary 1:  This post was originally completed aboard a cruise ship sailing for Glacier Bay, Alaska - just off the coast from Gustavus, Alaska about 48 miles west of Juneau.

That is me holding up the sign to Yukon (formerly known as the Yukon Territories) just north of Juneau and 600 miles south of the city of Dawson (formerly known as Dawson City).  My ancestors were given the name Dawson on Ellis Island, because their name was not pronounceable, so the founder of Dawson City is not a relative.

Supplementary 2:  Sometime after posting this, I discovered that the late David Foster Wallace had been interviewed by Terry Gross on her public radio program Fresh Air.  In that interview he talks about an article he wrote on going on a cruise and discusses that about 1/4 of the way down in the transcript.  He also wrote a piece called Shipping Out: On the (nearly lethal) comforts of a luxury cruise.  All of that writing can be found by search engines.  David Foster Wallace is an acclaimed writer and his writing about cruises is both accurate and entertaining.  It has an added dimension (especially in the Fresh Air transcript) of considering whether fun and enjoyment can be managed.

Admission, Discharge and Readmission Policies - No Better Example Of Business Driven Pseudoscience

One of the recurrent themes of this blog is that the application of science to medicine, especially at the public policy level has plummeted over the past three decades.  That has been directly attributable to the influence of business on all levels of government.  One of the more pervasive themes is that the behavior of health professionals is best accomplished by incentivization.  In other words financially punish physicians to get them to change their behaviors that you don't want or financially reward the behaviors that you want them to produce.  I haven't looked at the scorecard lately, but my guess is that the punishments greatly outweigh the rewards.  Maybe my perspective has been skewed by working for an HMO for many years that considered it a reward if they "held back" part of your salary and then gave it to you if all of the physicians in your group met the desired productivity targets.  I am sure it took the MBAs a while to dream that one up.  The equation seems to be as simple as -  "OK here is what we want the goal to be.  We don't want to pay out any rewards anymore.  Let's just penalize people for not meeting the goal until eventually everyone is compliant with the goal."  There is probably no better example than the Medicare Hospital Readmissions Program.

A recent editorial in JAMA notes that the 2013 readmission rates for Medicare patients is about 18% within 30 days (1).  That is associated with a potential cost of $26 billion.  Since 2010 Congress has levied a 3% of Medicare reimbursement penalty on hospitals who have readmission rates that are considered too high.  The problem is that 80% of hospitals are being penalized are safety-net hospitals or those that have a disproportionate share of low income patients.  Those hospitals are more likely to be penalized all three years since the penalty started  and they are more likely to be the hospitals with the lowest operating margins.  The likelihood of penalty also correlates with the percentage of patients treated who are elderly and live with poverty or disability.  

The authors opine that hospitals should not be penalized "because of the demographic characteristics of their patients."  They point out that the evidence suggests that is exactly what is happening and they conclude:  “Targeting hospitals for penalties, even if indirectly, simply because those hospitals care for more poor people is not good policy”.  They use this as a foundation to build their argument for a proposed policy initiative – The Hospital Readmissions Program Accuracy and Accountability Act of 2014.  It builds in safeguards for hospitals treating patients from a disadvantaged socioeconomic status.   

The obvious problem with the authors’ logic here is that they seem to not realize that discrimination against patients of the lowest socioeconomic status has been institutionalized and occurring for decades.  The people I am referring to are those people with addictions and severe psychiatric problems.  The facts are clear.  For the past 30 years, even though psychiatric disabilities rank as some of the top 10 disabilities by any measure, they get a much smaller fraction of the health care dollar for care.  I have used the example of a middle-aged man or woman being hospitalized through the emergency department for acute chest pain.  I don’t know the fraction of those people who are discharged the next day.  But consider that basic scenario if the evaluation of chest pain turns out to be non-cardiogenic.  In the hospital where I have worked that generally means an evening on telemetry and serial troponins and either a stress echocardiogram the next day or an echocardiogram and a stress test.  Price tag about $25-30,000 for less than 48 hours in the hospital.  On the other hand,  let’s say a person has an exacerbation of an affective psychosis and is not able to function at home or has put themselves at risk.  The will be hospitalized in a very low tech psychiatric unit, the goal of which is to discharge them when they are no longer “dangerous” or to discharge them upon request if they cannot be held involuntarily.  Irrespective of the price tag for this care the best available data I have on the DRG reimbursement for this care is about $4,800 irrespective of length of stay.  The economic incentives all line up to rarely provide them with the discharge resources they require to maintain even a subsistence life style and remain stable enough to stay out of emergency departments or jails.  Furthermore in many cases, states previously charged patients a for a portion of their medication costs per month out of their disability income.  The direct and indirect costs incurred by patients and families with severe mental illness and addictions are a travesty of the highest magnitude.  The rationing mechanisms that have been in place for the past three decades have results in care that is subpar relative to any other medical specialty.  It has created an entire population to patients with chronic illnesses that are discriminated against.  The financing of care for them has set a number of perverse incentives that would seem to be more destabilizing such as an incentive for hospital discharge in order to beat the designated days in the diagnosis related group (DRG) and readmit them if necessary.  If the entire DRG incentivization for admissions and discharges is pseudoscientific sleight-of-hand based on very crude demographic variables - why would we expect readmissions policies to be any different?

The second dimension of this care is just how unscientific care based on demographic factors is in the first place.  I was previously in a practice where “consultants” who had never practiced medicine came in and commented on the “complexity” of our patients.  At the time I was caring for many patients who I knew would never be admitted to other general psychiatric units in any other hospital in the state due to their medical complexity.  The consultants concluded that my patients were no more complex than any other patients in the state even though they could not define the measures they used to make that determination.  Nobody mentioned the inherent conflict of interest when a pro-discharge administration hires consultants that agree with their world view - discharge patients as soon as possible.

In another scenario and on a committee, I asked if the demographic determined characteristics and time lines for treating community acquired pneumonia led to any differences in mortality or complications – and nobody knew.  The original Big Data approach in medicine looked at HEDIS variables.  Any practicing physician knows this is an incredibly crude approach that in many cases is meaningless.  There is no better example than saying that treating acute and chronic psychosis in a few days makes no difference in outcomes, when nobody knows the best treatment approach and practically no hospital screens for functional or cognitive capacity - two well known areas of psychiatric disability.  In the outpatient sphere, it is the equivalent of saying that 10 or 20 minutes three or four times a year with an emphasis on medications that are not likely being taken by the patient can possibly affect their real life outcome.

In the case of patients with addictions the treatment is more dire.  When a person using heroin, alcohol, and excessive amounts of benzodiazepines cannot get admitted for detoxification or they cannot get admitted for residential treatment, society and its representative governments at all levels are saying that this is a situation where we can ignore conditions that are clearly life-threatening and in many cases fatal.  We can ignore them because businesses and governments say that this is a collection of disabling and life-threatening diseases that we can ignore so that they can either make money or divert money to treat more socially acceptable life-threatening and disabling diseases.  

This is all a clear pattern of discrimination that not only affects the elderly but anyone with a psychiatric disability or addiction.  If the authors want to do something about that – I say let’s start by reversing over 30 years of discrimination against those with psychiatric and substance use problems that is clearly based on socioeconomics especially the lack of a vocal political constituency, very poor research based on demographic variables rather than complexity, and a lack of innovative research based on poor resource allocation.

George Dawson, MD, DFAPA

References:

1: Boozary AS, Manchin J 3rd, Wicker RF. The Medicare Hospital Readmissions Reduction Program: Time for Reform. JAMA. 2015 Jul 28;314(4):347-8. doi: 10.1001/jama.2015.6507. PubMed PMID: 26219049.

Attribution:

Photo by Mark Buckawicki (Own work) [CC0], via Wikimedia Commons.